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PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Shoulder pain is a common symptom in primary care. It can be due to an intrinsic shoulder problem but pain can also be referred from other structures, such as the neck, diaphragm or the heart. Common shoulder problems share overlapping clinical features. When assessing shoulder pain, it is important to look for any 'red flags' that mean investigation and diagnosis need a more focused or urgent approach.

Anatomy of the shoulder joint

The humerus, glenoid, scapula, acromion, clavicle and surrounding soft tissues make up the shoulder. There are three significant articulations: the sternoclavicular joint, the acromioclavicular joint and the glenohumeral joint. The glenohumeral joint is the most commonly dislocated major joint in the body.

Ligaments and surrounding musculature, including the rotator cuff muscles, contribute to shoulder joint stability. The rotator cuff is composed of the four muscles: supraspinatus, infraspinatus, teres minor and subscapularis that interlock to function as one unit. These muscles help with internal and external rotation of the shoulder and importantly depress the humeral head against the glenoid as the arm is elevated. The tendons join together to form one tendon, the rotator cuff tendon. This passes through the subacromial space. The subacromial bursa, which has a large number of pain sensors, fills the space between the acromion and the rotator cuff tendon.[1]

Shoulder pain is the third most common cause of musculoskeletal consultation in primary care.

1% of adults with new shoulder pain consult their GP each year.

Self-reported prevalence of shoulder pain is between 16% and 26%.

Risk factors

Physical factors related to occupation including repetitive movements and exposure to vibration from machine tools.[3]

Psychosocial factors related to work may also be risk factors for shoulder pain, including stress, job pressure, social support and job satisfaction. However, in a systematic review, the associations were weak.[3]

Patients presenting in primary care often have a combination of different shoulder problems.

Intrinsic shoulder pain:

Rotator cuff disorders:

Rotator cuff tears.

'Subacromial pain', which may be due to impingement if the humeral head is not depressed sufficiently to slide under the acromion on elevation of the arm. It is also sometimes referred to as subacromial bursitis, tendonitis or tendinopathy.

There may be a history of heavy lifting or repetitive movements, especially above shoulder level. However, it often occurs in the non-dominant arm and in non-manual workers.

On examination there may be muscle wasting with pain on movements and a partial restriction of active movements (passive movements are full but painful).

A painful arc (between 70-120° of active abduction) is not specific or sensitive but increases the likelihood of a rotator cuff disorder.

A rotator cuff tear:

Usually follows trauma in young people. It is usually atraumatic in elderly people and caused by attrition from bony spurs on the undersurface of the acromion or intrinsic degeneration of the cuff, possibly.

Partial tears may be difficult to differentiate from rotator cuff tendinopathy on examination.

The drop arm test (see 'Examination', below) may be used to detect a massive tear.

Glenohumeral disorders

Adhesive capsulitis (frozen shoulder) and arthritis often present with a history of non-adhesive capsulitis symptoms, cause deep joint pain and restrict activities such as putting on a jacket - because of impaired external rotation.

Adhesive capsulitis is more common in people with diabetes and may also occur after prolonged immobilisation.

There is usually generalised shoulder pain and a restriction of passive and active movements.

As an initial screening test, ask the person to place the palms of their hands at the base of the neck with elbows pointing laterally and then to put their arms down and try to put the back of the hands between the shoulder blades. However, be aware that this also involves joints other than the shoulder (ie elbow, wrist).

Assess the power, stability and range of movement (active, passive and resisted) in both shoulders.

Look for a painful arc (pain between 70-120° of abduction).

Test passive external rotation (reduced in 'frozen shoulder'). With the elbow held into the side, turn the arm outwards as far as possible.

Perform the 'drop arm test': passively abduct the patient's shoulder. Then ask the patient to lower the abducted arm slowly to the waist. This can identify a massive rotator cuff tear. They may be able to lower the arm slowly to 90° because this uses mostly the deltoid muscle but, below 90°, the arm will drop to the side.

Perform the 'cross-arm test': this isolates the acromioclavicular joint. Ask the patient to raise the arm to 90° straight in front of them. Then ask the patient to adduct the arm across the chest. If there is an acromioclavicular joint problem, there will be pain in the area of the joint.

Management

There is a lack of well-designed clinical trials in the management of shoulder disorders. Management in primary care is usually conservative: reduce or avoid overhead activities; attention to any contributing factors; medication for pain relief, including corticosteroid injection. If symptoms don't settle quickly or are severe initially, physiotherapy focused on the specific cause is indicated.[8]

Refer to physiotherapy with the goal of optimising shoulder function, using an evidence-based rehabilitation protocol.[9]

Consider a subacromial corticosteroid injection if the person has limited function because of pain and is therefore unable to perform strengthening and stabilising exercises. They may be of short-term benefit when used alone.[8]See separate article Joint Injection and Aspiration.

Do not give a corticosteroid injection if:

The person has previously received a corticosteroid injection from an experienced practitioner with minimal or no benefit.

The person has already had three or more injections in the same shoulder in the previous year.

There is a suspected significant rotator cuff tear.

There is any contra-indication to corticosteroid injection (eg, infection, osteomyelitis).

Evidence shows that physiotherapy and steroid injections may be equally helpful in the short term.[10]Injections may be repeated if the initial response is good.

When calcific tendonitis is symptomatic, it may present as chronic, relatively mild pain in the shoulder, with sporadic episodes of severe, acute pain radiating down the arm or to the neck.

The calcium deposits cause a chemical irritant inflammatory reaction. There is also an increase in pressure in the tendon, which is turn leads to malfunction of the rotator cuff and subacromial pain.

Treatment for calcific tendonitis includes NSAIDs, corticosteroids, physiotherapy, aspiration or lavage. For patients refractory to these treatments, open or arthroscopic shoulder surgery may be offered to excise the deposit.

Extracorporeal shock wave lithotripsy is no longer recommended by the National Institute for Health and Care Excellence (NICE).

The humeral head may degenerate as a result of a range of conditions - eg, osteoarthritis, rheumatoid arthritis or avascular necrosis. The whole or only part of the articular surface of the humeral head may be affected.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but makes no warranty as to its accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions. For details see our conditions.